Welcome to the North Dakota Medicaid Provider newsletter.
Both leaves and temperatures have fallen bringing winter and a new year fast on their heels. A sincere thank you to each and every one of you for being a ND Medicaid provider and serving Medicaid members.
If you have any suggestions for future articles, please send your ideas to [email protected]. Let us know if there are ways to make this more informative or usable!
In this edition, you can learn about:
- Expanded Medicaid coverage for new moms,
- Stay Covered ND resources for members and providers,
- Meeting the electronic funds transfer requirement,
- Medication prior authorization updates,
- Upcoming dental changes,
- Approval of the most recent 1915(i) Medicaid State Plan Amendment,
- Faces of Medicaid initiative,
- How to deal with fraud and what happens when there is fraud, and more!
Expanded ND Medicaid coverage for new moms
ND Medicaid is expanding coverage for eligible new moms from 60 days to 12 months starting Jan. 1, 2023, to help address health needs after birth.
This additional coverage will allow new moms to receive full Medicaid benefits such as:
- Healthy mom checkups after birth,
- Ongoing care for diabetes, high blood pressure and other health needs,
- Dental care,
- Behavioral health services,
- Preventive care services like mammograms and cervical screens,
- Chiropractic care,
- Physical therapy, and
- Family planning services.
How can providers help?
If you work with ND Medicaid members who are pregnant, encourage them to tell their human service zone office right away that they are pregnant so they can receive this coverage.
They need to do this while pregnant in order to receive the expanded coverage. This must be done no matter which Medicaid program or category the member qualifies for.
Learn more at hhs.nd.gov/Medicaid/newmoms.
Medicaid renewals and Stay Covered ND resources
During the COVID-19 pandemic, the federal government temporarily stopped some Medicaid requirements and conditions to help people from losing their health coverage.
North Dakota will soon be required to review eligibility for people whose coverage was extended due to the COVID-19 public health emergency to make sure they still qualify.
We have created a webpage HHS.ND.GOV/StayCoveredND to give members, providers and other stakeholders information on what they need to do to prepare.
We need your help in spreading the word
When working with Medicaid members, encourage them to reach out to us to make sure we have their correct contact information. This is important as we may need to contact them about their coverage.
The webpage has information on how to do this along with other resources, including a recording of a recent stakeholder meeting.
The webpage will be updated with posters, flyers, video and other resources in the near future, so check it often.
Time is running out to meet the Electronic Funds Transfer (EFT) requirement! Deadline is December 31
North Dakota Health and Human Services is requiring all enrolled ND Medicaid providers to participate in electronic funds transfers (EFT) to receive Medicaid payments. N.D.C.C. 50-24.1-42
Providers need to complete and return the following items to ND Medicaid by faxing (701) 433-5956. You can also send a secure email or request a secure link from Noridian Healthcare Solutions by emailing [email protected].
You will need to send a completed SFN 661 and a bank letter or voided check. The information on the form must match the information provided in the bank letter or voided check.
Medicaid Expansion Providers
Because this requirement is specific to Medicaid payments, we advise that you also enroll for EFT with Blue Cross and Blue Shield of North Dakota (BCBSND) if you participate in the Medicaid Expansion program.
EFT enrollment for BCBSND’s Medicaid Expansion network can be sent to Availity within the transaction enrollment section.
If you have questions, contact BCBSND by emailing [email protected] or calling (800) 756-2749.
IMPORTANT: Paper remittance advices are being discontinued Jan. 1, 2023
Effective Jan. 1, 2023, ND Medicaid providers will no longer receive paper remittance advices (RAs). You can refer to this document for help in accessing the RA via the web portal.
If you have never accessed the web portal, you can register by clicking on the "Register" link located in the provider registration section of the ND MMIS Health Enterprise home page.
The user ID and password will be mailed in separate provider letters. Following that step, additional organization administrator accounts and other user accounts can be established. You may want to refer to the MMIS Organization Administrator fact sheet.
Security access will need to be set up with a user’s profile to allow staff to view and download the RA. Once a payment is made, you’ll receive a notice in the “Messages & Announcements” quick link on the MMIS home page. From there, you can go to the claims option of the top menu bar and drop down to payment inquiry. Your remittance advice will be located there.
You may contact the call center at 877-328-7098 with any questions.
Attention! Updated medication prior authorization information effective Jan. 1, 2023
Updates have been made to the medication prior authorization website.
The Preferred Drug List has been enhanced to provide consistent clinical criteria and preferred product placement across medical and pharmacy billing for medications. The coverage guidance tab now includes:
- a list of recently paid for over-the-counter medications and
- psychotropic monitoring program guidance.
Clinical criteria for requesting concurrent antipsychotics are in the Psychotropic Monitoring Program document.
Providers should use the prior authorization forms located under the PA Forms link and the NDC Drug Lookup tab to search for coverage details such as quantity, age and prior authorization rules.
Also, effective Jan. 1, 2023, Avsola and Renflexis will be the preferred infliximab products. All other infliximab products, including Remicade and its generic, will be nonpreferred and require prior authorization. Members currently using nonpreferred infliximab products will be required to switch to Avsola or Renflexis.
Other products that will require prior authorization beginning Jan. 1 include Tysabri, Stelara, Skyrizi, Entyvio, Simponi Aria and Orencia. Reference the Preferred Drug List for clinical criteria for these products.
Dental changes you should know about
On Jan. 1, 2023, ND Medicaid will be implementing the following changes.
ADULTS
ND Medicaid will allow two prophylaxis (D1110) or periodontal maintenance (D4910) for members ages 21 and older. This will not affect active frequency list authorizations.
Limits must be met/exceeded prior to consideration of additional visits per calendar year. Members who need three or four cleanings per year per the dental treatment plan will still be considered for frequency requests.
Also, ND Medicaid will allow either code D1206 - topical application of fluoride varnish or D1208 - topical application of fluoride, excluding varnish two times per calendar year for members ages 21 and older without service authorization. Service authorizations currently in place will not be affected.
Codes No Longer Requiring Service Authorizations
- D3310 – endodontic therapy, anterior tooth (excluding final restoration)
- D3346 – retreatment of previous root canal therapy – anterior
- D2950 – core buildup, including any pins when required
- D2952 – post and core in addition to crown, indirectly fabricated
- D2954 – prefabricated post and core in addition to crown
- D2955 – post removal
Note: When authorizing for crown services (D2710-D2799) pre- and post- endodontic radiographs are required for all ND Medicaid members.
YOUTH
ND Medicaid will allow code 99188 – Application of topical fluoride varnish by a physician or other qualified health care professional two times per calendar year as a separate benefit limit when billed on a CMS-1500 claim form for members through the age of 20.
1915(i) updates that are effective now!
North Dakota Health and Human Services is pleased to announce the approval of the most recent 1915(i) Medicaid State Plan Amendment, effective Nov. 1, 2022.
This amendment includes three important updates that will increase accessibility to in-home and community-based behavioral health services and supports for North Dakotans.
1) The rate methodology for 1915(i) nonmedical transportation is now billable per 15-minute unit. It previously was a flat, per round-trip rate. This change allows individuals to receive help to travel greater distances to meet their needs, when necessary. It also offers providers adequate reimbursement to expand both the geographical distance they travel and the time they dedicate to providing nonmedical transportation.
2) Provider shortage areas for 1915(i) are being decided in a new way moving forward. This will have a positive impact on which areas are exempt from the conflict of interest rule stating care coordination for an individual must be provided through a different agency than any/all other 1915(i) services. With the newly approved amendment, shortage areas are decided by monitoring 1915(i) provider enrollment. An area will only become nonexempt when the provider base is adequate to ensure individuals can still receive the services they need should the exemption not be in place. With the update, the only nonexempt areas are currently Cass County and Burleigh County. The exemption applies in all other areas of the state where an individual may receive care coordination and any/all additional services through one agency.
3) The qualifications for individual providers of the 1915(i) care coordination service are expanded to include those with more diverse educational backgrounds and/or practical experience.
These changes to the 1915(i) Medicaid State Plan Amendment were initiated based on valuable feedback from 1915(i) stakeholders.
Many thanks for your investment as we work together toward our common goal to help North Dakota “Become the Healthiest State in the Nation.” Please direct any feedback, questions, comments or concerns to nd1915(i)@nd.gov.
HHS and partner organizations launch Faces of Medicaid
Together with partner organizations, ND Health and Human Services (HHS) launched Faces of Medicaid to help North Dakotans understand who the ND Medicaid program serves and its life-changing impact.
The initiative features four individuals - Cuwe, Raya, Colin and Sandy. Each one shares their personal stories and experiences about how ND Medicaid has made a difference in their lives.
You can watch their stories on the Faces of Medicaid webpage.
These stories are made possible because of the care and support you provide to our members. Thank you!
The Faces of Medicaid initiative is a partnership between Blue Cross Blue Shield of North Dakota Caring Foundation, the Community HealthCare Association of the Dakotas, the North Dakota Hospital Association and HHS.
See press release.
Eyes on Fraud
Health care fraud causes financial losses estimated in the tens of billions of dollars each year according to the National Health Care Anti-Fraud Association (NHCAA).
Here are resources to help you and your organization prevent, detect and report fraud against the ND Medicaid program.
- Avoiding Medicare and Medicaid Fraud and Abuse booklet and instructional materials to share with your team members
- Health care compliance resources and toolkits offered by the federal U.S. Department of Health and Human Services
- Annual Report of the Departments of Health and Human Services and Justice, Health Care Fraud and Abuse Control Program FY 2021
- Quick Facts on Health Care Fraud Offenses from the U.S. Sentencing Commission FY 2021
What should you do if you suspect fraud?
You can report suspicions of ND Medicaid fraud, waste and abuse by:
- Phone: (701) 328-4024 or (800)-755-2604 (option 3)
- Email: [email protected]
- Complete a SFN 20 and return it by mail, fax or e-mail as instructed on the form
- Information is available the ND Medicaid Fraud and Abuse webpage.
What is a credible allegation of fraud?
State Medicaid agencies can suspend payments to providers when a credible allegation of fraud exists. The Code of Federal Regulations (CFR) says that a credible allegation of fraud may be an allegation, which has been verified by the state, from any source, including but not limited to the following:
(1) Fraud hotline tips verified by further evidence,
(2) Claims data mining, and
(3) Patterns found through provider audits, civil false claims cases, and law enforcement investigations.
Allegations are credible when they have signs of reliability, and the state Medicaid agency has reviewed all allegations, facts and evidence carefully and acts with good reason on a case-by-case basis.
Why are payments suspended in cases of fraud?
Suspension of payments in cases of fraud – 42 CFR § 455.3
(a) Basis for suspension.
(1) The state Medicaid agency must suspend all Medicaid payments to a provider after the agency determines there is a credible allegation of fraud for which an investigation is pending under the Medicaid program against an individual or entity unless the agency has good cause to not suspend payments or to suspend payment only in part.
(2) The state Medicaid agency may suspend payments without first notifying the provider of its intention to suspend such payments.
(3) A provider may request, and must be granted, administrative review where state law requires.
The Sometimes Missing Link - Documentation Requirements
Common denominators found in Program Integrity Unit (PIU) audits are the absence of or incomplete documentation.
The best possible health care may be delivered, but if the documentation doesn’t adequately support the services, payors are obligated to recover monies associated with that care. Caring for those treated is a cornerstone of all health care professions. This must be balanced with third-party payor expectations. Documentation of care is the connecting link.
Here are a few tips to ensure your documentation is where it needs to be.
- First and foremost, make sure every session billed has notes.
- Sign, date, and list your credentials at the conclusion of your notes.
- Don’t rely on electronic medical records to self-populate your notes. Make sure your notes have information relevant to this date of services and the overall care of the patient.
- Make sure your daily notes, plans of care, or goals are updated regularly and reflect the care being provided at each session.
Why is this important?
Provider documentation as the seamless connection between members, providers and ND Medicaid is an essential component of program integrity. The PIU must ensure documentation supports payment.
Providers should periodically review documentation for clarity and completeness to ensure it supports services provided before a PIU request occurs.
Filing Medicaid Provider Appeals in a Nutshell
ND Medicaid appeals must be timely. This means reviews of a payment denial must be filed within 30 days of the date of the agency’s denial of the claim. N.D.C.C. § 50-24.1-24(2)
Filing an appeal means requesting review of the denial using the ND Medicaid Provider Appeal Form (SFN 168) and a copy of the audit letter, if applicable.
Include the remittance advice (RA) number you are appealing, a statement of each disputed item with the reason for the dispute, and any other supporting documents.
Send your appeal to:
Legal Division
North Dakota Health and Human Services
600 E. Boulevard Avenue, Dept. 325
Bismarck, ND 58505-0250
If you have questions on the appeal process, contact the Legal Division at (800) 755-2604.
We want to hear from you! Please answer a few QUICK questions to tell us about opportunities for information sharing on policies.